Bevacizumab Injection Research Articles

Association Of Conjunctival Vitreous Reflux With Intraocular Pressure Spikes After Intravitreal Bevacizumab Injection

Objective: To evaluate the effect of conjunctival vitreous reflux on intraocular pressure immediately after intravitreal bevacizumab injection. Methods: A prospective interventional study was done at Benazir Bhutto Hospital, for 6 months from 13-01-2021 to 12-07-2021.Patients were selected through a non-probability consecutive sampling technique. A total of 88 eyes undergoing intravitreal bevacizumab were included in the study. IOP was checked before injection, immediately after injection, at 30 minutes and 60 minutes. The presence or absence of conjunctival reflux was noted. Data was analyzed to see the association of post-injection IOP and conjunctival reflux. Results: Those having conjunctival reflux positive had mean Intraocular pressure before intravitreal injection 13.14+2.569, the p-value was 0.0001. Immediately after injection at 0 minutes it was 27.95+3.988, and the p value was 0.0001. At 30 minutes, it was reduced to 21.58+2.814, the p-value was 0.0001, and at 60 minutes, the mean intraocular pressure was 17.26+1.853, and the p-value was 0.001. Those having conjunctival reflux negative had mean Intraocular pressure before intravitreal injection 13.44+2.981, p-value 0.0001. Immediately after injection at 0 minutes it was 33.69+5.608, and the p-value was 0.0001. At 30 minutes, it was reduced to 24.51+5.337, the p-value was 0.0001, and at 60 minutes, the mean intraocular pressure was 18.98+2.973, and the p-value was 0.001. Conclusion: Patients with vitreous reflux positive had less IOP elevation as compared to those with vitreous reflux negative. Keywords: Intravitreal bevacizumab injection, Intraocular pressure, conjunctival reflux.

Choroidal Osteoma with Choroidal Neo Vascular Membrane

Choroidal osteoma (CO) is a rare benign tumor usually unilateral and have a female preponderance. We report a case of a 34-year-old healthy malediagnosed with unilateral Choroidal Osteoma with an associated Choroidal NeoVascularMembrane(CNVM).Thediagnosiswasconfirmedbasedonclinicalexamination, typical findings on B-scan, Fundus fluorescein angiography,Indocyanine green angiography and Optical coherence tomography. The CNVMwas treated with intravitreal Bevacizumab injections and showed a good responseinitially.TherewasarecurrenceofCNVMovertwoyearswhenpatientwaslosttofollow-up. Treatmentwith intravitreal Ranibizumab bio similar injection helpedstabilize hisvision. Regular follow-up is essential for timely treatment ofrecurrenceof CNVMand optimum visualoutcomes.

Adjunctive bevacizumab therapy in an equine corneal stromal invasive squamous cell carcinoma with a 53-months follow-up.

A 17-year-old Appaloosa mare was referred for evaluation of presumed refractory keratitis of the left eye. Gross examination revealed ocular discomfort and corneal neovascularization with a nasal focal opacification affecting approximately 40% of the corneal surface. On ophthalmic examination, extensive subepithelial to mid-stromal vascular branching accompanied by a homogeneous white, dense opacification, which affected up to 80% of the total corneal thickness, were apparent. Signs of concurrent uveitis were absent. Deep-stromal lamellar keratectomy with a conjunctival pedicle graft was performed under general anesthesia. Histopathology confirmed a poorly differentiated corneal stromal invasive squamous cell carcinoma (SI-SCC) with neoplastic cell extension to the surgical margins. Postoperatively, 4 topical mitomycin C 0.04% chemotherapy cycles combined with oral firocoxib therapy were initiated. Seven months after surgery, regrowth of the SI-SCC was clinically suspected. A total volume of 1 ml bevacizumab 2.5% was administered in the standing sedated horse via 3 mid-stromal corneal injections. Four weeks later, intrastromal bevacizumab injections (ISBIs) were repeated, however, this time the solution was injected directly into the main corneal vessel branches.Seven weeks after the second ISBIs, the left eye was comfortable and significant remission of corneal vascularization and opacity was recognized. No recurrence has been noted for a follow-up period of more than 53 months.Equine SI-SCC usually has a very poor prognosis for globe maintenance. To the authors' knowledge this is the first report of well-tolerated intrastromal antivascular endothelial growth factor adjunctive therapy with bevazicumab 2.5% and SI-SCC resolution after a multimodal treatment approach.

Comparison of photodynamic therapy with two different parameters combined with subconjunctival injection of bevacizumab for corneal neovascularization

BackgroundTo the best of our knowledge, no studies have been performed to determine the optimal parameters of photodynamic therapy (PDT) combined with subconjunctival injection of bevacizumab for corneal neovascularization. This study aimed to compare the effect of photodynamic therapy with two different sets of parameters combined with subconjunctival injection of bevacizumab for corneal neovascularization. MethodsPatients with stable corneal neovascularization (CNV) unresponsive to conventional treatment (topical steroid) were included in this study. Patients were divided into two groups, receiving PDT with two different sets of parameters (group 1 receiving fluence of 50 J/cm2 at 15 min after intravenous injection of verteporfin with, group 2 receiving fluence of 150 J/cm2 at 60 min after intravenous injection of verteporfin with). Subconjunctival injection of bevacizumab was performed immediately after PDT. All patients were followed for 6 months. Best-corrected visual acuity and intraocular pressure were evaluated, and slit-lamp biomicroscopy as well as digital photography were performed. Average diameter and cumulative length of corneal neovascular were measured to evaluate the corneal neovascularization. ResultsSeventeen patients (20 eyes) were included in this study. At the last visit, the vision was improved in 12 eyes (60 %), steady in 4 eyes (20 %) and worsen in 4 eyes (20 %). The intraocular pressure (IOP) of all patients remained in normal range. A significant decrease in corneal neovascularization was showed in all the eyes after treatment. At 6 months after the combined treatment, the average diameter and cumulative length of vessels significantly decreased to 0.041 ± 0.023 mm (P < 0.05) and 18.78 ± 17.73 mm (P < 0.05), respectively, compared with the pretreatment data (0.062 ± 0.015 mm, 31.48 ± 18.21 mm). The reduction was more remarkable in group 2 compared to group 1.In group 1, the average diameter was 0.062 ± 0.013mm before and 0.056 ± 0.017mm after, the cumulative length of vessels was 38.66 ± 22.55mm before and 31.21 ± 17.30 after. In group 2, the date were 0.061 ± 0.016mm before and 0.029 ± 0.020mm after, 25.60 ± 8.95 mm before and 8.61 ± 8.26 mm. The reported complications included epithelial defect in four eyes, small white filaments in two eyes and corneal epithelial erosion in two eyes. ConclusionThe PDT combined with subconjunctival injection of bevacizumab was effective for the chronic corneal neovascularization. A more promising treatment outcome was observed when PDT was performed at 60 min after intravenous injection of verteporfin with fluence of 150 J/cm2. No serious complications or systemic events were observed throughout the follow-up period.

A Case Report on IRVAN Syndrome

Idiopathic retinal vasculitis, arteriolar macroaneurysms, and neuroretinitis (IRVAN) is a rare condition predominantly affecting young, healthy females without systemic disease. We present the case of a 35-year-old female who presented with a 3-month history of decreased visual acuity without associated symptoms. Ophthalmological examination revealed reduced visual acuity in both eyes, papillary oedema, stellate macular oedema, and haemorrhages bilaterally. Retinal imaging confirmed IRVAN syndrome. Treatment included pan-retinal photocoagulation (PRP) and intravitreal bevacizumab injections, resulting in macular oedema regression.

Preserving visual acuity: a compelling 12-year case study of controlling neovascular age-related macular degeneration

IntroductionIn neovascular age-related macular degeneration (nAMD) trials, anti-VEGF injection frequency decreases after the first year, while outcomes remain primarily related to the number of injections. To the best of our knowledge, there are no reports of maintaining the best corrected visual acuity (BCVA) for more than 7 years in extension studies.ObjectiveTo report a 12-year follow-up of a real-world case of nAMD where BCVA was preserved from declining.Case descriptionA 67-year-old Caucasian female presented to our department in June 2010 due to decreased vision in her left eye (LE) within the preceding months. Examination showed a BCVA of 85 letters (L) in the right eye (RE) and 35 L in the LE. Fundus examination showed drusen in the macula of both eyes. Macular edema, loss of the macular lutein pigment, macular hypo/hyperpigmentation were observed in the LE. A diagnosis of Type 2 choroidal neovascular membrane (CNV) in the LE was established and within two months a Type 1 CNV developed in the RE. She undergone 9 injections of bevacizumab (six) and ranibizumab (three) within the first year of treatment in the LE and seven injections of ranibizumab within the first year in the RE.ResultsThe LE had a mean of 5.2 injections per year, and the RE had a mean of 7.5 injections per year, from 2010 to 2022. RE's BCVA dropped by 8L (85L to 77L) and central retinal thickness (CRT) increased by 16 μm (276 μm to 292 μm) while LE’s BCVA increased by 28L (35L to 63L) and CRT decreased by 369 μm (680 μm to 311 μm), at the twelfth year.ConclusionsAlthough the final visual outcome depends on baseline BCVA and lesion type or size, the number of injections is paramount in preserving BCVA and achieving favorable functional outcomes in nAMD, even after 12 years of treatment.

Evaluation of Photodynamic Therapy-combined Intravitreal Bevacizumab in Age-related Macular Degeneration

Aim: It was aimed to compare treatment results of photodynamic therapy (PDT) and PDT-combined intravitreal bevacizumab injection (PDT+IVB) in patients with age-related macular degeneration (AMD). Material and Methods: 63 eyes of 55 patients with neovascular AMD were included. Group 1 consisted of 40 eyes of 35, group 2 consisted of 23 eyes of 20 patients. Visual acuity (VA), intraocular pressure measurement and fundus examination were performed. Pattern Electroretinography P50 amplitude and edema map values (EMV) were measured with Heidelberg Retina Tomograph (HRTII). Results: VA increased in 14, remained unchanged in 17, decreased in 9 eyes in Group 1 (PDT). The PERG P50 amplitudes were compared with values of pre-treatment, and found increased as 10.6%, 11.98%, and 8.46% and HRTII EMV were 5.86%, 4.88%, and 11.22% at 1st, 3rd, and 6th months, respectively. In Group 2 (PDT+IVB), VA improved in 9, remained unchanged in 8, decreased in 6 eyes. PERG P50 amplitudes were decreased as 10.15%, 5.8%, and 0.1% and HRTII EMV were decreased as 13.07%, 12.17%, and 14.87% at 1st, 3rd, and 6th months, respectively. Conclusion: Verteporfin and PDT are effective and safe methods that preserve VA in subfoveal choroidal neovascular membranes due to neovascular AMD.

Efficacy of Anti-VEGF in Treatment of Retinopathy of Prematurity

Retinopathy of prematurity (ROP) is a vasoproliferative retinal disorder that affects premature infants. Vascular endothelial growth factor (VEGF) has been implicated in the pathogenesis of ROP. Anti-VEGF agents can potentially inhibit abnormal vessel growth in ROP. This study aimed to evaluate the efficacy of anti-VEGF (bevacizumab) in treatment of ROP. A prospective study was conducted on 75 patients including 70 adults and 5 ROP babies who received intravitreal injection of bevacizumab (Avastin). Distant visual acuity, slit lamp examination, indirect ophthalmoscopy and optical coherence tomography (OCT) were assessed at baseline, immediate, 1 week and 4 weeks post injection. Statistically significant improvement was observed in distant visual acuity and reduction in macular thickness after Avastin injection. At 4 weeks, best corrected visual acuity of 6/6 was attained by 15 adults and 3 ROP babies. OCT revealed decreased macular edema with mean reduction of 115.29μm. ROP subjects showed greater visual gain (mean acuity improvement - 2.4 lines) as compared to adults (mean acuity improvement - 1.52 lines). Significant correlation was found between better visual acuity and macular thickness less than 300μm. Intravitreal Avastin resulted in rapid regression of neovascularization in ROP. No ocular or systemic complications were observed. Single injection controlled disease progression in majority of cases. Anti-VEGF agents can be considered as primary modality for treating type 1 ROP due to their safety, efficacy and long-term benefits. Larger studies are required to establish optimal dosage and long-term effects.

Topical Dorzolamide as Adjunctive Treatment With Intravitreal Bevacizumab in Bilateral Diabetic Macular Edema.

Intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents is accepted as the gold standard treatment for center-involving diabetic macular edema (CI-DME). Adjunctive administration of topical dorzolamide may enhance the therapeutic effects of anti-VEGF agents. In this study, we compared the efficacy of topical dorzolamide plus intravitreal injection of bevacizumab (IVB) versus IVB alone in patients with bilateral DME. This prospective, randomized contralateral eye study was carried out in a tertiary referral ophthalmology center, Al-Zahra Eye Hospital, Zahedan, Iran, between April 2021 and April 2022. Thisstudy included 50 eyes of 25 patients with bilateral DME. All eyes received three consecutive monthly injections of IVB. For each patient, one eye was randomized to instill dorzolamide eye drops three times a day as an intervention, and the other received artificial tear drops as a placebo. Best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) were evaluated before starting treatment and then monthly for the first three months. Among 25 included patients, the average age was 56.64 ± 7.97 years, and 48% were female. BCVA did not improve significantly in any groups (P > 0.05). No significant difference was observed in terms of BCVA between the intervention and control groups (P > 0.05). The present study showed a decrease in CMT in both study groups (P < 0.05). At month 3, the decrease in mean CMT from baseline was significantly higher in eyes receiving topical dorzolamide compared to the control group (-88.92 ± 82.90 vs. -37.64 ± 86.16 µM, respectively; P = 0.037). IOP decreased significantly only in eyes receiving dorzolamide (P < 0.001). The results of the present study indicate that adjunctive administration of topical dorzolamide has a beneficial effect on CMT reduction from baseline, but it did not have an additive effect on BCVA improvement compared to IVB monotherapy.

An Adolescent Case of Unilateral Papillophlebitis Treated with Intravitreal Bevacizumab

Purpose: To report a case of papillophlebitis treated with an intravitreal bevacizumab injection in an adolescent patient.Case summary: A 15-year-old female with no medical history presented with a 3-day history of blurred vision and a floating sensation. The initial visual acuity (VA) was 0.0 logarithm of minimal angle of resolution (logMAR) in the left eye. A fundus examination revealed a blurry disc margin, peripapillary hemorrhage, and venous engorgement. Optical coherence tomography indicated subretinal fluid (SRF) accumulation. Both color vision and pupillary reactions were normal in bilateral eyes. Blood tests revealed no significant abnormalities. Brain magnetic resonance imaging (MRI) showed mild focal papillitis, but the patient did not report eye movement pain or discomfort. The diagnosis was papillophlebitis; however, high-dose steroid treatment was not initiated due to the absence of a significant decrease in VA. A single injection of intravitreal bevacizumab was administered to address the SRF. At the 9-month follow-up, VA remained at 0.0 logMAR, and the retina demonstrated anatomical stabilization after complete absorption of the SRF without recurrence.Conclusions: Papillophlebitis can manifest during adolescence. Treatment of a 15-year-old patient with intravitreal bevacizumab obviated the need for high-dose steroid therapy and produced favorable outcomes, including preservation of VA and anatomical stabilization of the retina.

Impact of Pachychoroid and DRIL on the Treatment of Diabetic Macular Oedema with Intravitreal Bevacizumab.

To evaluate the long-term outcome of intravitreal bevacizumab in eyes with diabetic macular oedema (DME) following a PRN (pro re nata) regimen. Additionally, we investigated the effect of the presence of disorganisation of the retinal inner layers (DRILs) and pachychoroid (PC) at baseline on clinical outcome. This retrospective study included 112 naïve eyes with DME that were followed up for 2 years. All eyes were treated with six initial bevacizumab injections at monthly intervals and then received treatment according to a PRN regimen. In case of poor response to bevacizumab, therapy was switched to other agents. Main outcome measures included: best-corrected visual acuity (BCVA), central macular thickness (CMT), and number of intravitreal injections (IVI s). In addition, we examined the effect of the presence of DRILs and PC at baseline on clinical outcome. BVCA improved significantly and CMT decreased significantly during the first 2 years of treatment. The number of IVI s per eye was 11.1 ± 4.8 at the end of the second year. Treatment had to be switched to other agents in 47 eyes (42%). The timing of switching was 12.4 ± 6.1 months after a mean of 9.2 ± 3.3 IVI s. Patients with DRILs at baseline (29.5%) had significantly worse BCVA at all time points before and after treatment, although CMT was significantly lower before treatment and comparable to patients without DRILs during treatment. Patients with PC at baseline (35.7%) had no significant differences in BVCA and CMT at all time points compared with patients without PC. This study demonstrates statistically significant functional and anatomical improvement in patients with DME treated with intravitreal bevacizumab after 2 years. However, more than 40% of eyes required a switch in therapy. The presence of DRILs at baseline had a negative effect whereas the presence of PC at baseline had no effect on clinical outcome.

Suppression of Neovascularization by Topical and Subconjunctival Bevacizumab After High-Risk Corneal Transplantation

To assess the effectiveness of topical and subconjunctival bevacizumab in suppressing vascularization in graft and host bed after high-risk corneal transplantation. Secondary analysis of prospective, randomized, double-blind, placebo-controlled multicentric clinical trial. The study includes patients aged > 18 years who underwent high-risk penetrating keratoplasty, which was defined as corneal vascularization in ≥ 1 quadrants of the corneal graft and host bed, excluding the limbus. Patients were randomized to treatment and control groups. The patients in the treatment group received subconjunctival injection of bevacizumab (2.5 mg/0.1 ml) on the day of the procedure, followed by topical bevacizumab (10 mg/ml) 4 times per day for 4 weeks. The patients in control group received injection of vehicle (0.9% sodium chloride) on the day of procedure, followed by topical vehicle (carboxymethylcellulose sodium 1%) 4 times a day for 4 weeks. Vessel and invasion area of vessels in the corneal graft and host beds. This study included 56 eyes of 56 patients who underwent high-risk corneal transplantation, with equal numbers in the bevacizumab and vehicle (control) treatment groups. The mean age of patients who received bevacizumab was 61.2 ± 15.9 years, and the mean age of those treated with vehicle was 60.0 ± 16.1 years. The vessel area at baseline was comparable in the bevacizumab (16.72% ± 3.19%) and control groups (15.48% ± 3.12%; P= 0.72). Similarly, the invasion areas were also similar in the treatment (35.60% ± 2.47%) and control (34.23% ± 2.64%; P= 0.9) groups at baseline. The reduction in vessel area was significantly higher in the bevacizumab-treated group (83.7%) over a period of 52 weeks compared with the control group (61.5%; P < 0.0001). In the bevacizumab-treated group, invasion area was reduced by 75.8% as compared with 46.5% in the control group. The vessel area was similar at 52 weeks postprocedure in cases of first (3.54% ± 1.21%) and repeat (3.80% ± 0.40%) corneal transplantation in patients who received bevacizumab treatment. In the vehicle-treated patients, the vessel area was significantly higher in repeat (9.76% ± 0.32%) compared with first (8.06% ± 1.02%; P < 0.0001) penetrating keratoplasty. In the bevacizumab treatment group, invasion areas at week 52 were comparable in first (11.70% ± 3.38%) and repeat (11.64% ± 1.74%) procedures, whereas invasion area was significantly higher in repeat (27.87% ± 2.57%) as compared with first (24.11% ± 2.17%) penetrating keratoplasty in vehicle-treated patients. In patients undergoing vascularized high-risk corneal transplantation, bevacizumab is efficacious in reducing vascularization of corneal graft and host bed, thereby reducing the risk of corneal graft rejection in vascularized host beds. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Initial Outcome of Subconjunctival Bevacizumab for Corneal Neovascularization - a Case Series

Introduction : Corneal neovascularization (CNV) has a variety of causes and threatens corneal clarity, thus optimal visual acuity. Conventional medical management includes topical steroids and matrix metalloproteinase inhibitors like doxycycline. Anti-vascular endothelial growth factor (anti-VEGF) agents have demonstrated promise but remain off-label for this indication.&#x0D; Case Illustration : We present three patients with corneal neovascularization varied in etiology who underwent subconjunctival injection of Bevacizumab . Case 1: a-female-69 years old came with blurred vision after had Stephen Johnson Syndrome which affect her cornea. The examination revealed opacification of cornea accompanied by neovascularization at 5 until 9 o’clock position up to edge of pupil in the left. Case 2: a-male-47 years old presented corneal haze with neovascularization almostin all corneal region on background of fungal keratitis. Case 3: a-male-63 years old who underwent penetrating keratoplasty of indication corneal lekoma following an episode of fungal keratitis. There was opacity in all corneal region and neovascularization in 360 degree of limbus. All of these patients showed regression of neovessel after first injection of bevacizumab.&#x0D; Discussion : Corneal neovascularization is a condition caused by disruption homeostasis in which proangiogenic balanced by antiangiogenic, thereby maintaining avascularity. Bevacizumab as VEGF-A-binding proteins could prevent VEGF-A from binding cell surface receptors.&#x0D; Conclusion : Subconjunctival injection of Bevacizumab can be considered as a treatment for corneal neovascularization. It has shown promising effects in recess neovascularization in cornea regardlessthe etiology.

Bevacizumab vs Ranibizumab in Macular Edema due to Retinal Vein Occlusion: Short-term Outcomes

Introduction &amp; ObjectivesBevacizumab or Ranibizumab was widely used as therapy for macular edema (ME) in retinal veinocclusion (RVO) and diabetic retinopathy. The purpose of this study was to comparing short-termoutcomes for patients who received intravitreal Bevacizumab (IVB) injection or Ranibizumab (IVR)for ME due to RVO&#x0D; MethodsThis was observational, cross sectional study comparing patients received IVB or IVR. Primaryoutcomes data (visual acuity and central macular thickness/CMT) and secondary outcomes data(number injection and intra ocular pressure/IOP) were collected at baseline and 3 months afterinjection&#x0D; ResultsThere were 4 eyes in each group. There were no significant difference in mean change of visualacuity (-0.275±0.25 vs -0.15±0.5 logMAR; p=0.676) and CMT (-171.50±129.08 vs -98.25±37.67 um;p=0.345) in IVB vs IVR groups. There were also no significant difference in mean change of IOP(2±2.16 vs 2±4.69 mmHg; p=1) and number of injection (2.25±0.50 vs 1.75±0.9; p=0.401 ) in bothgroups.&#x0D; ConclusionIn short-term both IVB and IVB have relative similar outcomes on increasing visual acuity anddecreasing CMT in ME due to RVO

LONGITUDINAL CHANGES IN CHOROIDAL THICKNESS IN CHILDREN WITH A HISTORY OF PREMATURITY: An 18-Month Prospective Cohort Study.

To evaluate choroidal changes over time in school-age children with a history of prematurity. A study of 416 eyes of 208 eligible participants, including 88, 190, 36, 56, and 46 eyes in the full-term control, preterm, spontaneously regressed retinopathy of prematurity, intravitreal bevacizumab (injection of bevacizumab)-treated retinopathy of prematurity, and laser-treated retinopathy of prematurity groups, respectively, were enrolled in this study. The choroidal thickness was measured 4 times at 6-month intervals using optical coherence tomography. Of all the groups, the laser-treated children had the thinnest choroid compared with full-term children (-52.3 µ m, P = 0.04). Preterm children exhibited greater attenuation in choroidal thickness over time than did full-term children (-6.3 ± 26.9 and -1.1 ± 12.8 µ m/year, P = 0.03), whereas no difference was observed between injection of bevacizumab and laser treatments (-4.6 ± 18.9 and -2.0 ± 15.7 µ m/year, P = 0.46). In all groups, the changes in axial length were negatively associated with the changes in choroidal thickness (all P < 0.05). A greater attenuation in choroid thickness over time was observed in preterm children than in full-term children, but this attenuation did not differ between injection of bevacizumab and laser treatments. Axial elongation was associated with choroidal thinning in school-age children.

Trends in Anti-Vascular Endothelial Growth Factor Original Medicare Part B Claims in the United States, 2014–2019

ABSTRACT Purpose To characterize trends in use of and expenditure for the intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) agents aflibercept, ranibizumab, and bevacizumab among the population enrolled in Original Medicare from 2014 to 2019. Methods The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to extract Medicare Part B fee-for-service outpatient injection claims data submitted by ophthalmologists. Multivariable linear regression models were used to evaluate the association between reimbursement, ophthalmologist availability, and agent administration rate. Results Between 2014 and 2019, 17,588,995 intravitreal injection claims were filed by 4218 US ophthalmologists. Medicare costs for anti-VEGF injections increased from 2.51 B USD in 2014 to 4.02 B USD in 2019. Increased state-level ophthalmologist availability and incremental increases in average reimbursement amounts were found to be significantly associated with a 6.8-fold variation in 2019 overall anti-VEGF injection rates across states. Conclusions Medicare injection rates and costs for anti-VEGF injections have both increased between 2014 and 2019, largely driven by increased aflibercept use. There is a significant association between ophthalmologist availability and anti-VEGF injection rate on the state level, suggesting access to care may contribute to the observed state-level disparities in intravitreal injection rates. Further characterization of factors contributing to the state-level variation in injection rates of individual anti-VEGF agents may help inform interventions promoting equitable access to and use of these drugs.

Branch retinal vein occlusion treated with anti-VEGF: to switch or not to switch?

ObjectiveTo evaluate visual outcomes after switching from bevacizumab to ranibizumab or aflibercept in patients with macular edema (ME) secondary to branch retinal vein occlusion (BRVO). DesignA retrospective, multi-center, observational study. ParticipantsPatients diagnosed with BRVO and were treated with at least 3 bevacizumab injections, before anti VEGF switch. MethodsThe follow-up period was 36 months, and the primary study outcomes assessed changes in best corrected visual acuity (BCVA) after anti VEGF switch. ResultsA total of 263 eyes of 263 patients with a mean age of 71.5 ± 11.2 years of which 50% were of male gender met the inclusion criteria. Of them, 175 eyes did not undergo switch, whereas 88 eyes underwent anti-VEGF switch. There was not a significant difference in mean age (p = 0.634) and gender (p = 0.269) between the groups. Baseline BCVA of the no-switch group was 0.47 ± 0.43 logMAR (20/59 Snellen) versus 0.6 ± 0.49 logMAR (20/79 Snellen) (p = 0.031) in the switch group, and at 36-months it was 0.41 ± 0.39 (20/51 Snellen) logMAR versus 0.54 ± 0.49 logMAR (20/69 Snellen) (p = 0.035), respectively. The difference between the rate of change in BCVA per year was insignificant between groups (p = 0.414). In multivariate analysis, baseline BCVA was the single significant predictor for switch (beta 0.137, p = 0.035). Patients with more than one anti-VEGF switch suffer from decrease in BCVA. ConclusionsWorse baseline BCVA is a significant predictor for anti-VEGF switch execution, though the switch has no significant impact on the change in BCVA over time. Multiple anti-VEGF switch is not recommended.

Unilateral Retinopathy in a Preterm Infant With 4q Duplication: Description and Management.

A 33-5/7, 1570 g dichorionic diamniotic twin presented with cryptorchidism, failed hearing examination (both ears), poor feeding, profound hypoglycemia, coagulopathy, conjugated hyper-bilirubinemia, hydronephrosis, and hypotension. Microarray sent with results of whole genome SNP microgray analysis detected an interstitial duplication of the chromosomal segment 4q35 1q35.2. On this basis, telemedicine screening was performed to evaluate for ocular abnormalities in association with abnormal gene testing. Unilateral advanced retinopathy was noted affecting the right eye, with mature vascularization in the left eye. This infant was managed in concordance with retinopathy of prematurity guidelines, despite not making screening criteria. Off-label intravitreal bevacizumab injection (0.625 mg in 0.025 mL) resulted in full vascular maturation assessed by fluorescein angiography 6 months later. This represents the first description and management of retinopathy in 4q duplication syndrome. [Ophthalmic Surg Lasers Imaging Retina 2024;55:228-230.].

Calcified Sclero-Choroidal Choristomas in Mosaic RASopathies: A Description of a New Imaging Sign

PurposeTo evaluate the imaging and clinical features of unusual calcified lesions seen in the fundus of mosaic RASopathy patients. DesignSingle-center retrospective observational study. SubjectsTen eyes with calcified fundus lesions in 7 mosaic RASopathy patients. MethodsThe lesions were evaluated with fundus photography, oral fundus fluorescein angiography, B-scan ultrasonography, Magnetic Resonance Imaging (MRI), and Computed Tomography (CT) scan where available. Main Outcome MeasuresThe imaging characteristics of calcified fundus lesions were assessed. ResultsWe found seven patients with mosaic RASopathies, 5 males and 2 females (3 with Linear Sebaceous Nevus Syndrome, 3 with Oculoectodermal Syndrome, and 1 with Encephalocraniocutaneous Lipomatosis) with molecular confirmation in 5 cases, all 5 having KRAS-pathogenic variants. Calcified fundus lesions were identified in 10 eyes (bilateral in 3 patients), appearing as slightly elevated, creamy-yellow lesions around or adjacent to the optic nerve, extending supero-nasally; all but two of these lesions involved both the choroid and sclera, with two of them only involving the sclera at the time of examination. One case developed a choroidal neovascular membrane (CNV) necessitating intravitreal bevacizumab injections. All 7 patients had B-scan ultrasonography and the lesion appeared as a hyperechogenic area with an acoustic shadow posteriorly despite reduced gain. Five patients had MRI, and where fundus lesions were present, there was a focal defect in the sclero-choroidal layer. Four patients had a CT scan and all four showed calcifications affecting both the posteromedial sclero-choroid and adjacent medial rectus muscle. Two of these patients had normal eye movements, one had a unilateral fixed adducted eye and a vestigial fibrous medial rectus muscle seen in imaging and intraoperatively, and the fourth had marked exotropia with a right gaze deficit affecting both eyes. ConclusionsWe propose that the lesions seen in this cohort are calcified sclero-choroidal choristomas (CaSCCs) and should be suspected in mosaic RASopathies when creamy-yellow lesions are seen in the fundus. If identified, the possibility of choroidal neovascularization should be considered during follow-up. In all cases where a CT scan was performed, a novel sign of sclero-muscular calcification involving the medial rectus muscle was seen.

Comparison of intravitreal preservative-free triamcinolone versus posterior sub-tenon triamcinolone acetonide injection for bevacizumab-resistant diabetic macular edema

BackgroundTriamcinolone acetonide (TA) is administered as an intravitreal or posterior sub-Tenon’s capsule injection, as treatment for diabetic macular edema (DME). The intravitreal use of TA is limited because commercially available triamcinolone acetonide contains benzyl alcohol, a neurotoxic preservative. Few studies have compared effects of preservative-free intravitreal TA (IVTA) and posterior sub-Tenon capsule TA (STTA) injections for DME. Thus, herein, we compared the effectiveness of preservative-free IVTA and STTA for treatment of bevacizumab-resistant DME.MethodsIn this retrospective cohort study, bevacizumab-resistant DME was defined as a lack of response to at least three consecutive intravitreal bevacizumab (IVB) injections. Changes in mean central macula thickness (CMT), best-corrected visual acuity (BCVA), and intraocular pressure (IOP) between IVTA and STTA groups were compared at baseline and at 1, 2, and 3 months after treatment.ResultsForty eyes from 40 patients were included in this study. In the IVTA group, the mean CMT improved significantly from 400.2 ± 144.42 μm at baseline to 288.35 ± 151.74 μm at 3 months after treatment (p = 0.01). Similarly, in the STTA group, the mean CMT improved significantly from 446.65 ± 120.74 μm at baseline to 382.9 ± 113.58 μm at 3 months after treatment (p = 0.009). The mean BCVA of the IVTA group also showed improvement, decreasing from 0.75 ± 0.55 logarithm of the minimum angle of resolution (logMAR) at baseline to 0.625 ± 0.50 logMAR at 3 months after treatment (p = 0.089). Similarly, the mean BCVA of the STTA group improved, from 0.6 ± 0.36 logMAR at baseline to 0.54 ± 0.35 logMAR at 3 months after treatment (p = 0.094).ConclusionGiven that IVTA and STTA demonstrated statistically equivalent anatomical and functional effects in patients with bevacizumab-resistant DME, the less invasive STTA may be considered the preferred treatment approach for the management of bevacizumab-resistant DME.Trial registrationRetrospectively registered.